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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700499
Report Date: 04/24/2023
Date Signed: 04/24/2023 12:23:20 PM

Document Has Been Signed on 04/24/2023 12:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CASA DE STELLA LLCFACILITY NUMBER:
502700499
ADMINISTRATOR:HERNANDEZ, STELLAFACILITY TYPE:
735
ADDRESS:2210 CLOCK TOWER CTTELEPHONE:
(209) 869-4571
CITY:RIVERBANKSTATE: CAZIP CODE:
95367
CAPACITY: 5CENSUS: 5DATE:
04/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Stella HernandezTIME COMPLETED:
12:30 PM
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On 4/24/23 at approximately 10:15 Licensing Program Analyst (LPA) arrived at facility unannounced to conduct a required 1 year annual visit. LPA Jensen met with Licensee Stella Hernandez and explained the purpose of today's visit. Stella Hernandez holds current Administrator's certificate 6043871735 good through 5/26/23.

LPA Jensen toured the grounds and physical plant. The grounds were observed to be maintained, clear of debris and all paths were free of obstruction. The interior was observed to be sanitary and free of odor. There is a single designated entrance with a visitor sign in log and all required postings. There is adequate lighting and furniture inside and outside of the facility. The facility maintains a 2 day supply of perishable food and 7 day supply of non-perishable food. The menu is posted in a prominent area for viewing by the residents and is designed based on each clients food preferences. The knives and toxins were observed to be locked and inaccessible to residents in care. The facility posts a list of food that is expiring in the near future. There is also a log of refrigerator and freezer temperature that was complete through the current date. The thermostat was set at 73 degrees. The water temperature in the common bathroom on the main floor reads at 112.5 degrees which is within the required range. The emergency disaster plan was last updated in January of 2023 and is in compliance. The first aid kit was determined to be complete. There are night lights and emergency lighting available. Medications were observed to be locked and inaccessible.

LPA Jensen reviewed 2 of 5 resident files and 2 staff files. The staff files were determined to be complete. LPA Jensen reviewed the Medication Administration Record for 1 resident and determined it to be complete. In addition, the facility is documenting PRN effectiveness as required. LPA Jensen interviewed the 2 staff members present. All residents were out volunteering at a food bank at the time of the inspection.

The facility was determined to be in substantial compliance. An exit interview was conducted and a copy of this report was given
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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